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A New Vision for Veterans Care

Therapy-as-usual can't serve all the needs of our returning troops. Laurie Leitch, PhD, and Elaine Miller-Karas, LCSW, cofounders and codirectors of the Trauma Resource Institute, explain the scale of the problem and offer some practical solutions for those who suffer from PTSD.

Statistics measuring the effects of wartime service on our troops reveal high rates of drug and alcohol abuse, homelessness, homicide, suicide, divorce, depression, traumatic brain injury, and post-traumatic stress disorder. Yet, unless we're closely related to someone in the military, many of us still feel insulated from the impact of these wars, detached from the sacrifices of those fighting them, and removed from the problems they experience once they return to civilian life...

It's becoming increasingly clear that our mental health-care establishment, both civilian and military, isn't capable of handling this public health-care crisis. Those in the trenches of service delivery already know that our standard psychotherapeutic paradigm—one mental health professional with one client, applying one or several standard interventions—fails to meet the needs of this population, both because of the number of potential clients and the complexities of war trauma.

As professional psychotherapists, we need to rethink our ideas about how to reach out to the troops and their families struggling to return to ordinary life. It's time to move outside the limited conceptual box that now defines how we provide care to our homeward-bound warriors.

The Scale of the Problem

A report developed by the Rand Corporation in 2008 estimated that 300,000 veterans suffer from significant PTSD, anxiety, or major depressive symptoms; an additional 320,000 may have experienced a traumatic brain injury. The number of soldiers forced to leave the Army solely because of a mental disorder increased by 64 percent between 2005 and 2009.The actual numbers of veterans suffering from these problems is probably much higher than these figures indicate, because of the latent onset of PSTD in some individuals and the widespread misdiagnosis, or lack of diagnosis, of traumatic brain injury.

Meanwhile, divorce rates among returning troops are at record levels, particularly for women. According to the Army's Mental Health Advisory Team's 2007 survey, as many as 30 percent of soldiers and marines consider divorce by the midpoint of their deployment. Given the stressors that deployment imposes on entire family systems, it isn't surprising that cases of intimate partner violence and child maltreatment are up 30 percent in military couples and families.

In one study of 250,626 wives of active-duty United States Army soldiers receiving medical care between 2003 and 2006, those whose husbands were deployed for up to 11 months exhibited more than a six-percent increase in diagnoses of depression, anxiety, sleep disorders, acute stress reaction, and other problems over those whose husbands stayed home.

Unfortunately, the mental health system responsible for serving these men and women is already stretched to the breaking point, even as many thousands are returning to civilian life or are between multiple deployments. In a survey of its members by the National Council for Community Behavioral Healthcare, a nonprofit association of 1,600 behavioral health-care organizations, nearly two-thirds of the respondents said that veterans and their families, even when in crisis, report long delays and excessive wait times before they get to see a mental health provider.

In addition, it often takes veterans living in rural America as long as five hours to travel to a Veterans Affairs (VA) office or a military base for an appointment. Some don't have access to a vehicle or public transportation, or may be unable to drive or take public transportation because of combat-related physical and mental limitations. Civilian agencies already take up some of the slack: About 22 percent of veterans seek mental health-care outside the VA system.

Most clinical interventions, including cognitive-behavioral therapy, exposure therapy, EMDR, and exposure therapy using virtual reality, are delivered in standard clinical formats: one-on-one or group therapy sessions provided by professional psychotherapists. These interventions are expensive, time-consuming, and often unavailable outside urban areas, and there aren't enough trained therapists to deliver them to the many thousands of troops and veterans suffering from PTSD and the array of other war-related symptoms.

There's also a growing chasm between the number of military personnel who need mental health services and who actually try to get them. Many of those who are experiencing the unseen wounds of war frequently avoid seeking help, fearing that they'll be stigmatized as "weak" or "crazy" by their peers and superiors—that they'll be, in effect, abandoning the fight and "letting down" their battle buddies because they can't take the pressures of war...

Even if they do muster the courage, dogged persistence, and time it takes to get the help they need from overloaded facilities, the usual therapy models may not be appropriate for the complex physical, spiritual, and emotional wounds resulting from the unique circumstances of these seemingly interminable wars. The way our therapy establishment—military and civilian—is organized isn't necessarily effective with the kinds of chronic trauma resulting from protracted and repeated deployments to war zones. Nor do therapeutic models—with their focus on treating the individual—mesh well with the realities of military culture and its communal values...

Military Culture & War Trauma

All work with our troops needs to be "culturally appropriate," taking into account the special context of the military culture and combat setting. Not only does the military have its own language, filled with formal and informal acronyms, but its own organizational structure, values, and expectations, along with rigorous training designed to override our natural biological programming to avoid danger and seek safety at all costs. The life-saving skills warriors learn impart focus, competence, self-confidence, and inner strength that can keep them and their comrades alive in a combat zone.

What makes it even harder for those with war-related trauma and other emotional disorders to get the help they need is that therapists often don't understand the unique, confounding, and anomalous situation of the war zone...The intense and inherent ambiguities of war are complicated further by the current demands of counterinsurgency tactics, which require warriors to be somehow both friend and foe—at one moment, they're conducting full-combat operations, and in the next, handing out candy and soccer balls.

They may be engaged in a variety of noncombat missions with the local people, all the while not knowing who the enemy is. The warrior thus becomes the reluctant diplomat to people, including women and children, who, if she lets her guard down, may try to kill her.

Today's wars are increasingly fought and supported by women warriors, even though there's a lag between current legislation prohibiting women from being in combat roles and the actual roles women are playing. Although women may perform the same duties as men, including fighting, their unrecognized status may detrimentally impact credit for the risks they take and disqualify them from receiving awards and services as veterans.

The incidence of gender-based violence, commonly referred to as Military Sexual Trauma (MST), is another disturbing factor in today's wars. According to interviews with female veterans, there's secrecy and shame about being a victim of MST, along with fear that reporting it will damage opportunities for advancement or add to the risk of combat. Because of warriors' dependency on others in their units, especially those superior in rank, MST can be experienced similarly to childhood sexual abuse by a trusted family member, engendering commensurate feelings of shame and distrust of others.

A New Vision

So a kind of "perfect storm" is brewing: we have a large and growing population of war-weary troops and veterans; a mental health-care system lacking the person-power to treat them; and conventional professional therapeutic approaches that fail to recognize the uniqueness of military culture and trauma.

Current clinical interventions like CBT, EMDR, and Exposure Therapy may be helpful to many of those who seek assistance, but even if enough therapists and mental health facilities were providing these treatments, many individuals would miss out on help because of stigma, cost, fear, distance, or the unpleasantness and intensity of the therapy.

Understandably, many active military and veterans resent being labeled with a psychiatric diagnosis, regardless of how their symptoms are categorized in the DSM. They don't want to be, nor should they be, pathologized for having done what they deeply believed was their duty and later suffered disproportionately for it.

A critical shift is needed in how we think about the challenge of helping so many struggling young men and women. Traditional methods that rely primarily on professional practitioners operating within the mental health establishment can't respond to a problem of this scale. We need to provide healing alternatives that build on the resiliency of the human mind-body system, rather than assumed pathology. We need to do this—at least as a first line of approach—within a nonclinical community setting that won't alienate these clients or make them feel worse, while taking advantage of local organizations, peer-group support, and family participation.